Provider Demographics
NPI:1821489451
Name:FULLERTON, VONEDA JANE (AA)
Entity Type:Individual
Prefix:
First Name:VONEDA
Middle Name:JANE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SE 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1200
Mailing Address - Country:US
Mailing Address - Phone:503-235-0131
Mailing Address - Fax:503-239-7390
Practice Address - Street 1:200 SE 7TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1200
Practice Address - Country:US
Practice Address - Phone:503-235-0131
Practice Address - Fax:503-239-7390
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health